Wednesday, November 26, 2014

You might as well be ready for it, especially if you, like me, support the Affordable Care Act and work in a field related to healthcare: Obamacare will be brought up over Thanksgiving Dinner by one of your relatives, particularly if they are convinced by watching Fox News that it is the worst thing ever.

You can hope, of course, that they won’t, because it will probably just lead to mutual bad feelings and indigestion. You could try to shift the conversation away from Obamacare to something less controversial, like whether the Washington Redskins football team should change its name (okay, not a good alternative topic!), or immigration (okay, another bad alternative—maybe there just aren’t any topical subjects out there that won’t make someone mad). You could try to ignore their Obamacare rants, but I haven’t found that to be terribly effective in my own Irish-American extended family. (Irish-Americans are drawn to a good argument like a moth is drawn to flame, often with similarly calamitous results).

Or you could try to answer with a reasoned discussion of why you support Obamacare—while recognizing that some of your relative’s objections to the law may be supported by their own personal experiences and personal philosophy.

You are almost certainly going to hear about Jonathan Gruber, the MIT economist and so-called Obamacare “architect” who was recorded on video as implying that Obamacare was passed by taking advantage of the “stupidity” of the American voter. I personally wouldn’t try to rise to Mr. Gruber’s defense about these particular remarks—calling the voters stupid was, well, stupid. But it might be helpful for you to know that although Mr. Gruber provided advice to the administration, mainly by creating a statistical model to simulate its impact, he was not the “architect” of the Affordable Care Act in any real sense of the word, as Politico documents in a well-researched story.

The substantive point that Mr. Gruber was evidently trying to make, as a private citizen to an academic audience, is that Obamacare works by transferring money—through higher health insurance premiums and taxes, from the well-off and the well, to help pay for health insurance for the less well-off and the less well, and that the administration wasn’t particularly transparent about it. (Medicare, which is highly popular, does the same—those who are younger, healthier and working subsidize care for older and sicker retirees). It is probably true that many Americans do not understand that Obamacare, and Medicare for that matter, transfer dollars from those who are healthier and wealthier to those who are less healthy and wealthy, but that hardly makes them stupid. And it is also true that the Obama administration and congressional Democrats downplayed the redistributive aspects of the ACA when trying to sell it to the voters—although in my near 36 years of experience in the political process, I have found that all politicians, of all political stripes, promote their ideas by emphasizing the things the voters want to hear, not the parts that will upset them.

And Gruber’s remarks were hardly a smoking gun revelation about Obamacare’s redistributive impact. Conservative critics of Obamacare have been well aware that the subsidies the law offers to sicker and poorer people to help them afford insurance comes from healthier and wealthier persons—which is precisely the reason that many have been philosophically opposed all along! For instance, The Wall Street Journal made exactly this point in an editorial published just a few months after the law’s enactment).

Now, if you try to explain all of the above about Jonathan Gruber to your upset relative, you probably won’t have a particularly pleasant Thanksgiving dinner. So it might be best just to acknowledge that whatever Mr. Gruber meant to say, and no matter what his role in Obamacare was and was not, his “stupidity” remarks were offensive and wrong.

But what is worthy of philosophical debate, independent of Gruber’s controversial comments, is the fundamental question of whether every American should have access to health insurance coverage, no matter how sick they are, where they work and live, or how much or how little they earn. If your answer is yes, then you would have to acknowledge, and be willing to try to persuade others, that the only way that this can be accomplished is by redistributing dollars, through higher premiums and taxes, from those who are fortunate enough to be healthier and wealthier and have insurance, to those who are less healthy, less wealthy, and can’t afford to buy health insurance on their own.

If you philosophically oppose such redistribution, maybe at least in part because you are in the category of people who are paying more under Obamacare to help the less fortunate afford health insurance, then you have to be willing to acknowledge if the Affordable Care Act were to be repealed, the result will be millions more people will have to go without health insurance coverage. (Studies show that many of them will be sicker and die younger as a consequence). Is that an acceptable outcome to you? If not, what would you propose instead?

This is a debate worth having, because it is the fundamental dividing line between those of us who support the Affordable Care Act as a just and moral way to help those who are less fortunate have access to health care, even if some of us who are more fortunate have to pay more, and those who believe it is unjust and immoral for the government to collect money from some to subsidize healthcare for others.

This is a worthy debate to have, although having it over Thanksgiving dinner might still not be the best idea. Not if you don’t want to have mashed potatoes hurled in your general direction, that is!

Happy Thanksgiving!

Today’s question: What will you say if Obamacare is brought up by a relative or guest at your Thanksgiving dinner?

Thursday, November 6, 2014

Cynicism appears to have replaced idealism as America’s defining characteristic. So many of us just don’t trust the government, scientists, the clergy, journalists, business CEOs, labor unions, lawyers, or just about anyone for that matter, to say or do the right thing.

Two years ago, the National Journal reported that as a consequence of the Great Recession, “Americans are losing faith in the institutions that made this country great.” The Pew Research Center finds that public trust in government has “reached an all time low;” in 1958, a whopping 73% of Americans expressed trust in the federal government; by 2013, only 24%, said they trusted it much of the time.

The Gallup organization has surveyed the public over the past four decades about how much trust they place in various institutions and professions. The Economix blog has converted Gallup’s data into an interactive graph that tracks changes in opinion over the decades. “Click on almost any category charted in the graph,” Catherine Rampell wrote for Economix, “and you’ll see that confidence has generally been falling.”

Even the medical profession, which has relatively enjoyed higher “confidence” ratings and hasn’t suffered as steep declines as other sectors, does not fare so well when compared to other countries. Harvard researchers found that “based on data from an international health care survey, the United States is near the bottom of the list when it comes to public trust in the medical establishment”—ranked 24th in the world, on par with Croatia.

The public’s lack of trust in science and scientists is particularly alarming.

Take the Ebola controversy. The National Journal’s Ron Fournier says that “the scariest thing about Ebola” is what it says about trust in U.S. government and institutions.

“Once again,” he observed, “Americans are reminded of the limits of U.S. social institutions—in this case various state, local, and federal government agencies and private-sector health systems that responded to the Ebola crisis slowly, inefficiently, and with a lack of candor that Americans, unfortunately, have come to expect.” Such lack of faith in leadership, he noted in a follow up commentary, has led to “outrageous” policy outcomes, like mandatory quarantines of nurses and doctors. Why is this so?

“The governors don't trust the scientists who oppose a mandatory quarantine for health care professionals exposed to Ebola,” writes Fournier. “The White House doesn't trust the governors. The governors don't trust the White House. Doctors don't trust nurses. Nurses don't trust hospital administrators. Hospital administrators don't trust federal officials, and the Feds don't trust them. Nobody trusts the media. The public trusts nothing. This rampant lack of faith in each other and in our institutions is how we got to a place where the state of New Jersey is holding a courageous 33-year-old nurse hostage.”

As ACP noted in its own statement, “mandatory quarantines for asymptomatic physicians, nurses and other clinicians, who have been involved in the treatment of Ebola patients, whether in the United States or abroad, are not supported by accepted evidence on the most effective means to control spread of this infectious disease. Instead, such mandatory quarantines may do more harm than good by creating additional barriers to effective treatment of patients with Ebola and impede global efforts to contain and ultimately prevent further spread of the disease.” The CDC, the Infectious Diseases Society of America, and Dr. Dr. Anthony Fauci, director of the National Institute of Allergy and Infectious Diseases, are all in agreement with us.

The problem is that Americans don’t trust what the experts tell them: 71 percent of them back mandatory quarantines of health professionals that treated Ebola patients in West Africa.

Or take the growing numbers of Americans who refuse to vaccinate themselves or their children. A recent study found that “In some areas, nearly one out of five children has not received their recommended vaccines. The consequences are serious not only for those unprotected children, but for the rest of society as well. ‘Herd immunity’ is threatened as more and more parents free ride off of the community's dwindling immunity, and outbreaks of diseases thought to have been conquered have already occurred.”

Opposition to vaccinations actually increased when anti-vaccine parents were given accurate scientific information about them, another study found. “Researchers focused on the now-debunked idea that the vaccine for measles, mumps and rubella (or MMR) caused autism. Surveying 1,759 parents, researchers found that while they were able to teach parents that the vaccine and autism were not linked, parents who were surveyed who had initial reservations about vaccines said they were actually less likely to vaccinate their children after hearing the researchers messages.”

Or take climate change. The Washington Post reports on a study that confirms that 97% of scientists agree that human activities are causing the planet to warm. A new report from the United Nation’s Intergovernmental Panel on Climate Change concludes that "If left unchecked, climate change will increase the likelihood of severe, pervasive and irreversible impacts for people and ecosystems.” The World Health Organization concludes that global warming will affect “the social and environmental determinants of health – clean air, safe drinking water, sufficient food and secure shelter. Between 2030 and 2050, climate change is expected to cause approximately 250,000 additional deaths per year, from malnutrition, malaria, diarrhea and heat stress. The direct damage costs to health (i.e. excluding costs in health-determining sectors such as agriculture and water and sanitation), is estimated to be between US $2-4 billion/year by 2030. Areas with weak health infrastructure – mostly in developing countries – will be the least able to cope without assistance to prepare and respond.”

Yet too many Americans are disbelieving of the scientific consensus: Gallup reports that more than four out of ten say that the seriousness of global warming is exaggerated.

If we allow the cynics to carry the day, we will all pay a steep—and perhaps lethal—price.

If we don’t trust the scientists, doctors, and public health agencies on Ebola, then what will happen if we have a flu pandemic that threatens millions? Will we tune out the recommendations from the experts about what science tells us needs to be done to limit spread of the disease? How many will die as a result?

If we don’t trust scientists, doctors, and government agencies on the safety and effectiveness of childhood vaccinations, won’t we be condemning thousands of kids to die from diseases that could have been prevented?

If we don’t trust the scientific consensus on health consequences of global warming, aren't we putting millions of lives around the world at risk of harm and even death from diseases, unsafe water, poor air, insufficient food, and insecure shelter?

British historian and author Kenneth Clark once said that “We can destroy ourselves with by cynicism and disillusion, just as effectively as by bombs.” I fear that the rising tide of American cynicism may be bringing us closer to that day.

Today’s questions: Why are Americans so cynical? Are you one of them? Do you agree that cynicism, and especially distrust of science and scientists, are putting us at risk?

Wednesday, November 5, 2014

By decisively taking control of the U.S. Senate and increasing their majority in the House of Representative, the Republicans now have a chance to force some modest changes in the Affordable Care Act, but they will not be able to repeal or reverse it. But Republican gains in state legislatures and governorships may put the brakes on Medicaid expansion, leaving millions without coverage.

First, let’s start by acknowledging that although the mid-term election may have been a referendum on President Obama, it wasn’t a referendum on Obamacare. Exit polls show that only 25 percent of voters named Obamacare as the top issue for them compared to 45 percent who named the economy. 47 percent of those who cast ballots in the mid-term elections said that Obamacare went too far, but another 48 percent said that the law was just about right or did not go far enough.

Second, even though Republicans will have sizeable majorities in both chambers of Congress, they will not be able to repeal Obamacare, because they don’t have the 60 votes required to overcome a Democratic filibuster, and if they were somehow able to get a repeal bill to the president, they don’t have the two-thirds super-majority in both chambers needed to override a veto by President Obama.

Third, the Republican-controlled Congress may be able to advance legislation to alter parts of Obamacare that are peripheral, but not essential, to getting people covered, like the taxes on medical devices and insurance companies, and repeal of the Independent Advisory Board, potentially with enough Democratic votes to get a bill to the president. (Practically speaking, IPAB is probably dead in the water anyway, since IPAB appointees would have to be confirmed by the Senate, and there is no realistic prospect that a majority of Republican senators would agree to confirm appointments to a body that they oppose in the first place). One problem for Republicans is that repealing the medical device and insurance taxes, and eliminating IPAB, would be scored by the Congressional Budget Office as increasing the budget deficit, unless Republicans find alternative savings or revenues to make up the difference, whether they're from the ACA itself or from somewhere else.

Other Obamacare changes that Republicans can be expected to pursue would include cutting off funding for the subsidies to insurers that are available if insurers experience adverse selection in the ACA’s exchanges, which most Republicans view as a taxpayer “bailout” to insurers. They will also try to eliminate the requirement that large employers provide coverage for full-time employees, and if they can’t repeal the mandate altogether, they will try to modify how many hours count as full-time employment for the purposes of the mandate. (Health policy experts disagree on how essential the employer mandate is to the success of the Affordable Care Act). While the GOP will try to pass a bill to repeal the tax penalty on people who do not buy ACA-qualified coverage—the so-called individual insurance requirement—President Obama would veto it. Republicans may also seek to make it easier for people whose insurance is “cancelled” to keep their policies, but this would be difficult to achieve without driving up premiums for everyone else.

The GOP may also try to block administration efforts to do a work-around on the Supreme Court’s Hobby Lobby ruling that the federal government cannot force “closely held” companies to provide coverage for certain types of contraceptives. They could also try to overturn the administration’s ruling that members of Congress and their staffs, who are required to buy insurance coverage through the ACA’s exchanges, can continue to get the premium contribution that the federal government usually makes to its employees as part of their compensation package, which some Republicans have [mis]characterized as a “special subsidy” or exemption. They could also try to cut funding to federal agencies for ACA implementation.

Republicans likely will try to attach the changes they are seeking in the ACA to “must pass” bills like the debt ceiling, repeal of the Medicare SGR formula, and appropriations bills to fund the federal government. They may also try to get changes in budget reconciliation, which requires only a simple majority. But no matter what vehicle they use to pass the bills, the only changes that Republicans will be able to make in the ACA are ones that the President agrees to, which means that the most important parts of the ACA will remain intact.

Fourth, Republicans will use their control of Congress to exercise more oversight over the administration’s implementation of the ACA. Expect more adversarial hearings on www.healthcare.gov, especially if there are problems with the next enrollment period that starts on November 15, or if people start getting new cancellation notices, or if premiums go up. Expect Congress to exercise more oversight over Medicare’s Center on Medicare and Medicaid Innovation and the ACA’s Prevention and Public Health Fund, which some Republicans view as unaccountable “slush” funds that are outside of Congress’s budget control.

Fifth, two programs important to primary care physicians may face tough sledding in the new Congress, because they were created by the ACA. One is Medicaid primary care pay parity, which is set to expire at the end of this year, unless Congress authorizes an extension of it during the upcoming “lame duck” session. Otherwise, it will fall to the new 114th Congress to decide whether to reestablish it. The other is the Medicare 10 percent primary care bonus program, which sunsets at the end of 2015. Because both of these programs were created by “Obamacare” and because they cost money, many Republicans will be disinclined to support their continuation. Physicians will have their work cut out in trying to persuade Republican lawmakers to support both programs on their own merits—as programs crucial to ensuring access to primary care doctors—rather than viewing them as extensions of Obamacare.

Sixth, with more states having Republican governors and legislatures, continued progress in expanding Medicaid may be slowed, leaving millions of poor Americans in the “coverage gap” (ineligible for Medicaid, ineligible for Obamacare’s premium subsidies). The New York Times reports that:

“Republicans in Florida, Wisconsin,
Maine and Kansas won their bids for re-election. Three of them — Scott Walker
in Wisconsin, Sam Brownback in Kansas and Mr. LePage in Maine— oppose expansion
of the program. Rick Scott, the Republican governor of Florida, has endorsed
the expansion, which would extend coverage to an estimated 848,000 people, but
has never advocated for it forcefully, and he is not expected to now. And one
state that has expanded its program might reverse course. In Arkansas, the
legislature has to reauthorize the program every year with a three-quarters
majority, leaving the expansion vulnerable to political shifts. Asa Hutchinson,
a Republican who appears to be unenthusiastic about the expansion, was elected
governor. And opponents of expansion picked up two critical votes in the state
Senate.”

In other states, GOP gains in state legislatures may make their states even more resistant to expanding Medicaid, even if the governor supports it. Wisconsin may be one of the few remaining big-state wildcards on Medicaid expansion: although the voters re-elected Republican governor Scott Walker, an ardent opponent of Medicaid expansion, they also overwhelmingly passed a non-binding referendum calling on the state to accept federal dollars to expand Medicaid. Whether the referendum will soften Governor Walker’s opposition remains to be seen.

So the bottom line of the 2014 election is this: Obamacare is here to stay, the Republican-controlled Congress will likely be able to get some peripheral elements of it changed but will not be able to repeal or reverse it, and recent progress on Medicaid expansion may be slowed, leaving millions without coverage.

Today’s question: what is your take on the impact of the 2014 elections on Obamacare?